Affordable Care Act Factsheets

The Affordable Care Act Just the Basics

Obamacare

Affordable Care Act

The goal: to give more Americans access to quality, affordable health insurance.

ACA/Obamacare 101 Americans must sign up during the annual Open-Enrollment Period.

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Insurers can NOT consider health status or gender when charging for insurance. They can consider indvidual v. family, geography, age, and tobacco use.

10 Essential Health Benefits

All health plans MUST cover at least the 10 essential health benefits,

PLUS full contraceptive coverage Prescription Drugs

Insurers must spend 80-85% of your premium on medical care or write you or the employer a rebate check.

Rehabilitative Services & Drugs

The system used to purchase health coverage is called The Marketplace or The Exchange. States may have their own names as well, i.e. Access Health CT. These are run by the states, the federal government, or a combination of the two.

If you purchase health insurance through the Exchange/Marketplace, you will have access to 3-4 levels of health plans: bronze, silver, gold, platinum. Each level will provide a different percent of health coverage.

Lab Services

Preventative Services (counseling, screenings, vaccines)

Pediatric Services (includes dental & vision)

Tax Subsidies, calculated based on income, are available to individuals and families to help pay for health insurance.

Outpatient Care

For states that opt in, Medicaid coverage is expanded to include people up to 133% of poverty line. Federal government covers majority (90-100%) of Medicaid bills.

All businesses with equivalent of 50+ full time employees must provide health insurance.

Emergency Services

(non-hospital related care)

(trips to ER)

Hospitalization

Maternity & Newborn Care

Mental Health & Substance Abuse Care

Individual Mandate

Requires most Americans to obtain and maintain health insurance or pay a tax penalty.

Goal: to enroll enough healthy people to balance out the number of sick people.

The penalty? $695 or 2.5% of income, whichever is greater.

Lifetime, Annual Limits THEN. Pre-ACA, plans set annual and/or lifetime limits. The insurer would cover up until a dollar amount.

Once that dollar amount was reached, you were required to cover all remaining health care costs.

NOW. The ACA bans insurers from putting annual or lifetime dollar limits on all essential benefit services.

Pre-Existing Conditions ?

People who have a health condition, such as an illness or pregnancy, or who are at higher than average risk of needing health care are referred to as having a pre-existing health condition.

1 in 2 to1 in 5 THEN. Pre-ACA, insurers denied coverage OR charged high rates.

Americans have a pre-existing condition.

NOW. Post-ACA, insurers cannot deny or reduce coverage based on pre-existing conditions.

Sources: Healthcare.Gov; Congressional Budget Office; Politico Understanding Obamacare (http://bit.ly/1j51Bi7)

The Affordable Care Act Let’s Talk Pre-Existing Conditions

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What is a Pre-Existing Condition

A pre-existing condition is a health condition that exists before someone applies for or enrolls in a new health insurance policy. Insurers typically define what constitutes a pre-existing condition.

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How many suffer?

Denial of Coverage

As many as 1 in 2 (129 million) non-elderly Americans suffer from pre-existing conditions. Other sources site 1 in 5 (50 million) Americans with pre-existing conditions.

As many as 400 conditions qualify as pre-existing for purposes of insurance coverage being denied/altered. These include chronic diseases, previous medical procedures, and child-bearing or adopting status.

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Diabetes

Insomnia

Cancer

Malignant mole

Heart Disease

Adopting a child

High blood pressure

IBS

Pregnancy (current)

Migraine Headaches

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What happened before the ACA? Because of pre-existing conditions, insurance companies in the individual/small group markets could:

36%

deny coverage;

of Americans who tried to purchase health insurance were turned down, charged more, or had a health problem excluded from coverage.6

charge higher premiums;

The Affordable Care Act Passes

limit benefits to individuals

This process is called medical underwriting.

With the passage of the Affordable Care Act came a ban on medical underwriting.

In other words, insurers cannot deny coverage, charge higher premiums, or limit benefits to individuals because of a pre-existing condition. In fact, they cannot ask about pre-existing conditions when calculating insurance rates.

The balancing act:

The ban on medical underwriting makes the individual mandate critical. Remember, the individual mandate says every American must have health insurance or pay a penalty.

Individual Mandate

Ban on Medical Underwriting

Sick people

Insurers are required to provide coverage to all applicants at roughly the same price. This means that everyone must be required to buy coverage - hence the individual mandate.

Healthy people

The goal is to try to balance the number of sick people enrolled, against the number of healthy people enrolled. Without the individual mandate, the concern is that mostly people with pre-existing conditions would enroll, essentially bankrupting the insurance companies.

With the ACA, uninsured rates declined by almost 20 percent or more among non-elderly Americans. with high blood pressure, behavioral health disorders, asthma or chronic lung disease, and osteoarthritis.

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A Repeal

We do not know what a repeal will look like and what impact it will have on individuals with pre-existing conditions.

Proposals include: 1 Full repeal, i.e no coverage of pre-existing conditions; 2 Replacement, i.e. maintaining current handling of pre-existing conditions; 3 No lapse, High Risk pools, i.e. people with pre-existing conditions are insured if their current coverage does not lapse or is not lost. If lost, they will enter high-risk pools which means expensive, bad coverage.

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under the age of 65 would have difficulty getting private 52 million people coverage with a repeal due to pre-existing conditions.

Sources: 1| https://www.hhs.gov/healthcare/about-the-law/pre-existing-conditions/index.html 2 | https://www.healthinsurance.org/blog/2015/08/19/why-pre-existing-conditions-mattered-to-millions/ 3, 8 | https://www.hhs.gov/about/news/2017/01/05/new-analysis-uninsured-rate-americans-pre-existing-conditions-dropped-sharply-when-major-affordable

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4 | http://kff.org/health-reform/press-release/an-estimated-52-million-adults-have-pre-existing-conditions-that-would-make-them-uninsurable-pre-obamacare/ 5 | https://aspe.hhs.gov/basic-report/risk-pre-existing-conditions-could-affect-1-2-americans 6 | https://healthnetwork.com/blog/before-the-aca-1-in-7-people-were-denied-coverage-because-of-pre-existing-conditions-today-none/ 7 | http://kff.org/health-reform/issue-brief/high-risk-pools-for-uninsurable-individuals/